Lemmel’s Syndrome, an Unusual Cause of Abdominal Pain · PDF fileobstructive jaundice...
5
© 2014 The Korean Academy of Medical Sciences. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. pISSN 1011-8934 eISSN 1598-6357 Lemmel’s Syndrome, an Unusual Cause of Abdominal Pain and Jaundice by Impacted Intradiverticular Enterolith: Case Report Duodenal diverticula are detected in up to 27% of patients undergoing upper gastrointestinal tract evaluation with periampullary diverticula (PAD) being the most common type. Although PAD usually do not cause symptoms, it can serve as a source of obstructive jaundice even when choledocholithiasis or tumor is not present. This duodenal diverticulum obstructive jaundice syndrome is called Lemmel’s syndrome. An 81-yr-old woman came to the emergency room with obstructive jaundice and cholangitis. Abdominal CT scan revealed stony opacity on distal CBD with CBD dilatation. ERCP was performed to remove the stone. However, the stone was not located in the CBD but rather inside the PAD. After removal of the enterolith within the PAD, all her symptoms resolved. Recognition of this condition is important since misdiagnosis could lead to mismanagement and therapeutic delay. Lemmel’s syndrome should always be included as one of the differential diagnosis of obstructive jaundice when PAD are present. Keywords: Enterolith; Lemmel’s Syndrome; Periampullary Diverticulitis Hyo Sung Kang, Jong Jin Hyun, Seung Young Kim, Sung Woo Jung, Ja Seol Koo, Hyung Joon Yim, and Sang Woo Lee Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea Received: 5 October 2013 Accepted: 10 December 2013 Address for Correspondence: Jong Jin Hyun, MD Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital 123 Jeokgeum-ro, Danwon-gu, Ansan 425-707, Korea Tel: +82.31-412-4856, Fax: +82.31-412-5582 E-mail: [email protected] http://dx.doi.org/10.3346/jkms.2014.29.6.874 • J Korean Med Sci 2014; 29: 874-878 INTRODUCTION Periampullary diverticula (PAD) refer to extraluminal outpouch- ings of duodenal mucosa that develop within the radius of 2 to 3 cm from the ampulla of Vater (1). PAD are largely asymptom- atic but they sometimes can cause both pancreaticobiliary and non-pancreaticobiliary complications. Rarely, obstructive jaun- dice can develop secondary to PAD in the absence of choledo- cholithiasis or tumor and is termed Lemmel’s syndrome (2). Recently, the authors experienced an unusual case of abdomi- nal pain and obstructive jaundice due to extrinsic compression of mid common bile duct (CBD) by distended PAD filled with pus-like material as a result of impacted intradiverticular en- terolith at the PAD orifice. Herein, we report a case Lemmel’s syndrome that was successfully managed endoscopically. CASE DESCRIPTION An 81-yr-old woman presented to the emergency department on August 3, 2012 with nausea, vomiting, fever (38.4°C), and diffuse abdominal pain of 4 days’ duration. She had undergone subtotal gastrectomy with billroth II anastomosis due to peptic ulcer perforation 10 yr ago. On physical examination, there was tenderness on her right upper quadrant but Murphy’s sign was equivocal. Her white blood count was increased to 11,170/µL (neutrophil 83.0%) and CRP was elevated to 2.392 mg/dL. e results of her liver function test were as follows: total bilirubin, 2.37 mg/dL; aspartate aminotransferase, 88 IU/L; alanine ami- notransferase, 96 IU/L; alkaline phosphatase, 349 IU/L; and γ-glutamyl transpeptidase, 571 IU/L. To evaluate the cause of diffuse abdominal pain with liver enzyme elevation in a choles- tatic pattern, abdominal CT scan was taken. e axial images of the CT scan demonstrated distal CBD stone with upstream bile duct dilatation (Fig. 1A). However, on coronal reconstructed images, the stone was not located within the bile duct but in- side the PAD and the distended diverticulum was compressing the mid CBD (Fig. 1B, 1C). Magnetic resonance cholangiopan- creatography (MRCP) also revealed mid CBD compression and absence of choledocholithiasis (Fig. 1D). ese findings were confirmed on endoscopic retrograde cholangiopancreatogra- phy (ERCP) which showed normal biliary orifice (Fig. 2A) with impacted dark brown pigment stone (henceforth enterolith) at the PAD orifice (Fig. 2B). When the enterolith was pushed into the diverticulum by cannulation catheter and contrast dye was injected (Fig. 2C, 3A), old blood clots and pus-like fluid gushed out from the opening (Fig. 2D). Biliary cannulation combined with endoscopic sphincterotomy (EST) was also performed to explore the CBD for other possible causes of obstructive jaun- dice but no stone, stricture or obstruction by tumor could be found. On endoscopic nasobiliary drainage (ENBD) tubogram, stenosis at mid CBD was also shown to be resolved, likely be- cause the PAD had been decompressed (Fig. 3B). After con- firming that no other pathology was present, intradiverticular enterolith was crushed and removed by Dormia basket on the CASE REPORT Gastroenterology & Hepatology
Transcript of Lemmel’s Syndrome, an Unusual Cause of Abdominal Pain · PDF fileobstructive jaundice...
copy 2014 The Korean Academy of Medical SciencesThis is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (httpcreativecommonsorglicensesby-nc30) which permits unrestricted non-commercial use distribution and reproduction in any medium provided the original work is properly cited
pISSN 1011-8934eISSN 1598-6357
Lemmelrsquos Syndrome an Unusual Cause of Abdominal Pain and Jaundice by Impacted Intradiverticular Enterolith Case Report
Duodenal diverticula are detected in up to 27 of patients undergoing upper gastrointestinal tract evaluation with periampullary diverticula (PAD) being the most common type Although PAD usually do not cause symptoms it can serve as a source of obstructive jaundice even when choledocholithiasis or tumor is not present This duodenal diverticulum obstructive jaundice syndrome is called Lemmelrsquos syndrome An 81-yr-old woman came to the emergency room with obstructive jaundice and cholangitis Abdominal CT scan revealed stony opacity on distal CBD with CBD dilatation ERCP was performed to remove the stone However the stone was not located in the CBD but rather inside the PAD After removal of the enterolith within the PAD all her symptoms resolved Recognition of this condition is important since misdiagnosis could lead to mismanagement and therapeutic delay Lemmelrsquos syndrome should always be included as one of the differential diagnosis of obstructive jaundice when PAD are present
Keywords Enterolith Lemmelrsquos Syndrome Periampullary Diverticulitis
Hyo Sung Kang Jong Jin Hyun Seung Young Kim Sung Woo Jung Ja Seol Koo Hyung Joon Yim and Sang Woo Lee
Division of Gastroenterology and Hepatology Department of Internal Medicine Korea University College of Medicine Seoul Korea
Received 5 October 2013Accepted 10 December 2013
Address for CorrespondenceJong Jin Hyun MDDivision of Gastroenterology and Hepatology Department of Internal Medicine Korea University Ansan Hospital123 Jeokgeum-ro Danwon-gu Ansan 425-707 KoreaTel +8231-412-4856 Fax +8231-412-5582E-mail sean4hkoreaackr
httpdxdoiorg103346jkms2014296874 bull J Korean Med Sci 2014 29 874-878
INTRODUCTION
Periampullary diverticula (PAD) refer to extraluminal outpouch-ings of duodenal mucosa that develop within the radius of 2 to 3 cm from the ampulla of Vater (1) PAD are largely asymptom-atic but they sometimes can cause both pancreaticobiliary and non-pancreaticobiliary complications Rarely obstructive jaun-dice can develop secondary to PAD in the absence of choledo-cholithiasis or tumor and is termed Lemmelrsquos syndrome (2) Recently the authors experienced an unusual case of abdomi-nal pain and obstructive jaundice due to extrinsic compression of mid common bile duct (CBD) by distended PAD filled with pus-like material as a result of impacted intradiverticular en-terolith at the PAD orifice Herein we report a case Lemmelrsquos syndrome that was successfully managed endoscopically
CASE DESCRIPTION
An 81-yr-old woman presented to the emergency department on August 3 2012 with nausea vomiting fever (384degC) and diffuse abdominal pain of 4 daysrsquo duration She had undergone subtotal gastrectomy with billroth II anastomosis due to peptic ulcer perforation 10 yr ago On physical examination there was tenderness on her right upper quadrant but Murphyrsquos sign was equivocal Her white blood count was increased to 11170microL (neutrophil 830) and CRP was elevated to 2392 mgdL The results of her liver function test were as follows total bilirubin
237 mgdL aspartate aminotransferase 88 IUL alanine ami-notransferase 96 IUL alkaline phosphatase 349 IUL and γ-glutamyl transpeptidase 571 IUL To evaluate the cause of diffuse abdominal pain with liver enzyme elevation in a choles-tatic pattern abdominal CT scan was taken The axial images of the CT scan demonstrated distal CBD stone with upstream bile duct dilatation (Fig 1A) However on coronal reconstructed images the stone was not located within the bile duct but in-side the PAD and the distended diverticulum was compressing the mid CBD (Fig 1B 1C) Magnetic resonance cholangiopan-creatography (MRCP) also revealed mid CBD compression and absence of choledocholithiasis (Fig 1D) These findings were confirmed on endoscopic retrograde cholangiopancreatogra-phy (ERCP) which showed normal biliary orifice (Fig 2A) with impacted dark brown pigment stone (henceforth enterolith) at the PAD orifice (Fig 2B) When the enterolith was pushed into the diverticulum by cannulation catheter and contrast dye was injected (Fig 2C 3A) old blood clots and pus-like fluid gushed out from the opening (Fig 2D) Biliary cannulation combined with endoscopic sphincterotomy (EST) was also performed to explore the CBD for other possible causes of obstructive jaun-dice but no stone stricture or obstruction by tumor could be found On endoscopic nasobiliary drainage (ENBD) tubogram stenosis at mid CBD was also shown to be resolved likely be-cause the PAD had been decompressed (Fig 3B) After con-firming that no other pathology was present intradiverticular enterolith was crushed and removed by Dormia basket on the
CASE REPORTGastroenterology amp Hepatology
Kang HS et al bull Lemmelrsquos Syndrome Due to Impacted Enterolith
httpjkmsorg 875httpdxdoiorg103346jkms2014296874
A B C D
Liver
PV
CBD
GB
PAD
Fig 1 Computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) findings of the biliary tract On axial CT scan a high attenuated stone density with internal air (black arrow) is seen on distal common bile duct (CBD) (A) However coronal reconstructed image shows that the stone (black arrow) is not located in the CBD but within the periampullary diverticulum that is filled with air and debris along with mid CBD stricture (white arrow) (B) This finding is depicted in line art to better delineate the anatomical relationship (C) Absence of CBD stone and mid CBD stricture is also demonstrated on MRCP image (D)
A B C
D E F
Fig 2 Endoscopic retrograde cholangiopancreatographic findings of enterolith within the periampullary diverticulum (PAD) and its removal A dark brown pigment stone (white arrow) is seen impacted at the orifice of the PAD (A B) When the stone is pushed upward into the PAD (C) old blood clots is seen gushing out from the PAD orifice (D) The enshyterolith within the PAD is being fragmented and removed with Dormia basket (E F)
following day (Fig 2E F) After the procedure the patient no longer complained of abdominal pain her liver enzyme was normalized and she was discharged without any complication She had been well until 6 months after enterolith removal when the patient visited the outpatient clinic with vague abdo-minal discomfort Laboratory examination only revealed slight-ly increased total bilirubin to 196 mgdL but a large CBD stone
was found on abdominal CT scan (Fig 4A) When the CBD stone was removed by ERCP the stone proved to be brown pigment sludge stone that typically forms in the presence of ascending infection (Fig 4B C) PAD at this time was neither distended nor filled with enterolith Follow-up ERCP was performed again after 6 months but there was no recurrence of CBD stone or en-terolith She remains clinically and radiographically disease
Kang HS et al bull Lemmelrsquos Syndrome Due to Impacted Enterolith
876 httpjkmsorg httpdxdoiorg103346jkms2014296874
A B C
Fig 3 Fluoroscopic images When dye is injected into the PAD an ovoid shaped filling defect (white arrow) can be seen (A) Endoscopic nasobiliary drainage tubogram obtainshyed after decompression of the PAD demonstrates resolved extrinsic compression (B) After completion of enterolith removal filling defect is no longer seen within the PAD (C)
A B C
Fig 4 Removal of common bile duct (CBD) stone Followshyup computed tomography scan taken about 6 months after enterolith removal shows an ovoid stone (white arrow) within the CBD (A) CBD stone (white arrow) removed by Dormia basket (B) proved to be brown pigment sludge stone (C)
free after the last procedure
DISCUSSION
Diverticula of the gastrointestinal tract are outpouchings of all or part of the intestinal wall which can occur anywhere through-out the alimentary tract The most common site of gastrointes-tinal diverticula is colon followed by duodenum which was first described by Chomel in 1710 (3) The detection rate of du-odenal diverticula ranges from 1 to 27 depending on the di-agnostic modalities used and the average age at the time of di-agnosis (1) Among duodenal diverticula PAD is the most com-mon type comprising about 70 to 75 of all duodenal diver-ticula (1) Most PAD are asymptomatic but complications can occur in about 5 of cases and they include bleeding perforation di-verticulitis pancreatitis choledocholithiasis cholangitis jaun-dice enterolith or bezoar formation intestinal obstruction etc Among these complications hepatocholangiopancreatic dis-
ease can seldomly occur in the absence of choledocholithiasis and is termed Lemmelrsquos syndrome (2) Pathologic mechanisms through which Lemmelrsquos syndrome is thought to occur include the following First diverticulitis or direct mechanical irritation of PAD may cause chronic inflammation of ampulla and lead to chronic fibrosis of papilla (papillitis chronica fibrosa) (4) Sec-ond PAD many cause dysfunction in the sphincter of Oddi (5) Third distal CBD or ampulla can be directly compressed me-chanically by PAD that is usually filled with enterolith or bezoar (6 7) In our case enterolith that formed within the PAD did not directly compress the distal CBD but it obstructed the PAD ori-fice instead This obstruction combined with inflammation of the diverticulum and collection of pus-like material within the obstructed PAD seems to have expanded the PAD with resul-tant extrinsic compression of mid CBD (Fig 1) This was quite different from previous cases in which compression occurred at distal CBD PAD normally have a relatively wide orifice There-fore the enterolith bezoar or food material within the PAD is frequently evacuated and thus the symptom could be intermit-
Kang HS et al bull Lemmelrsquos Syndrome Due to Impacted Enterolith
httpjkmsorg 877httpdxdoiorg103346jkms2014296874
tent However PAD in our case had a narrow opening likely due to repeated inflammation of the PAD and this seems to have hindered the clearance of entrapped enterolith out into the du-odenal lumen Enterolith formation within the duodenal diverticula is known to be facilitated in the static environment such as a blind loop after gastrectomy or proximal portion of stricture formed by Crohnrsquos disease or tuberculosis (8) In our case blind loop cre-ated by Billroth II anastomosis seems to have provided a static environment favoring enterolith formation within the PAD Dur-ing enterolith removal CBD was also explored to search for oth-er possible source of obstructive jaundice such as CBD stone since primary biliary stone is known to occur more frequently in the presence of PAD (9 10) One possible mechanism be-hind increased occurrence of primary CBD stone in these pa-tients involves colonization and overgrowth of β-glucuronidase producing bacteria within the PAD that spread into the bile duct which in turn leads to deconjugation of bilirubin glucuronides and eventually results in precipitation of calcium bilirubinate gallstones (11) Although CBD was explored in our case no other etiology of obstructive jaundice could be identified other than extrinsic compression by distended PAD However pri-mary bile duct stone newly developed on follow-up ERCP per-formed 6 months later (Fig 4) The most plausible explanation is that EST performed during CBD exploration at the time of enterolith removal has permitted the occurrence of ascending infection with resultant brown pigment stone formation Diagnosing Lemmelrsquos syndrome could be challenging but being aware of this condition is important to avoid mismanage-ment and it begins with identification of PAD PAD are best de-monstrated using a side-viewing endoscope during ERCP On CT scan and MRCP PAD appear as thin-walled cavitary lesions situated on the medial wall of the duodenum 2nd portion that typically contain gas However PAD are sometimes filled with fluid and can frequently be mistaken for pancreatic pseudocyst pancreatic abscess cystic neoplasm in the pancreas head or even metastatic lymph node (12 13) Therefore high index of suspicion is mandatory to arrive at a correct diagnosis in these patients In our case enterolith within the PAD on axial images was at first mistaken for distal CBD stone due to its distal loca-tion combined with upstream dilatation of the bile duct (Fig 1A) However upon careful scrutinization of the coronal recon-structed images it became evident that the stone was located within the PAD (Fig 1B C) which was eventually confirmed by ERCP (Fig 2) Treatment is generally not recommended in asymptomatic patients or would be conservative management in pauci-symp-tomatic patients Nevertheless since most patients with Lem-melrsquos syndrome present with symptoms related to biliary ob-struction (ie jaundice abdominal pain and cholangitis) as a result of extrinsic compression of CBD some form of treatment
is advocated Therapeutic options in this situation run the gam-ut from endoscopic extraction of entrapped material extracor-poreal shock wave lithotripsy to surgery (diverticulectomy or biliodigestive anastomosis) (7 14 15) The patient in our case was also successfully treated endoscopically by fragmenting and removing enterolith using a Dormia basket It should be kept in mind that not all forms of Lemmelrsquos syndrome are caused by extrinsic compression of CBD by bulging PAD If the under-lying mechanism of Lemmelrsquos syndrome is likely to be due to papillitis chronica fibrosa or sphincter of Oddi dysfunction as mentioned above the simplest and the most appropriate man-agement would be to perform EST (16) In conclusion Lemmelrsquos syndrome is a rare cause of obstruc-tive jaundice that should be included in the differential diagno-sis of biliary obstruction when PAD is present Maintaining a high index of suspicion is imperative to establish an accurate diagnosis since it can mimic other cystic or solid lesions around the pancreas head Symptomatic patient can be successfully managed endoscopically in many instances but recourse to surgical management would be necessary in selected cases
REFERENCES
1 Lobo DN Balfour TW Iftikhar SY Rowlands BJ Periampullary divertic-
ula and pancreaticobiliary disease Br J Surg 1999 86 588-97
2 Lemmel G Die Klinische Bedeutung der Duodenal Divertikel Arch Ver-
dauungskrht 1934 46 59-70
3 Chomel JB Report of a case of duodenal diverticulum containing gall-
stones Histoire Acad R Sci Paris 1710 48-50
4 Manabe T Yu GS Duodenal diverticulum causing intermittent- persis-
tent cholestasis associated with papillitis chronica fibrosa N Y State J
Med 1977 77 2132-6
5 Tomita R Tanjoh K Endoscopic manometry of the sphincter of Oddi in
patients with Lemmelrsquos syndrome Surg Today 1998 28 258-61
6 Rouet J Gaujoux S Ronot M Palazzo M Cauchy F Vilgrain V Belghiti J
OrsquoToole D Sauvanet A Lemmelrsquos syndrome as a rare cause of obstruc-
tive jaundice Clin Res Hepatol Gastroenterol 2012 36 628-31
7 Nishida K Kato M Higashijima M Takagi K Akashi R A case of Lem-
melrsquos syndrome caused by a large diverticular enterolith at the peripapil-
lary portion of the duodenum Nihon Ronen Igakkai Zasshi 1995 32
825-9
8 Shocket E Simon SA Small bowel obstruction due to enterolith (bezoar)
formed in a duodenal diverticulum a case report and review of the liter-
ature Am J Gastroenterol 1982 77 621-4
9 Tham TC Kelly M Association of periampullary duodenal diverticula
with bile duct stones and with technical success of endoscopic retrograde
cholangiopancreatography Endoscopy 2004 36 1050-3
10 Lee JH Lee JS Kim HW Bae SM Kim SH Kang DH Song CS Song GA
Cho M Yang US Association of periampullary diverticula with primary
choledocholithiasis Korean J Gastroenterol 1999 33 252-7
11 Skar V Skar AG Bratlie J Osnes M Beta-glucuronidase activity in the
bile of gallstone patients both with and without duodenal diverticula
Scand J Gastroenterol 1989 24 205-12
Kang HS et al bull Lemmelrsquos Syndrome Due to Impacted Enterolith
878 httpjkmsorg httpdxdoiorg103346jkms2014296874
12 Macari M Lazarus D Israel G Megibow A Duodenal diverticula mim-
icking cystic neoplasms of the pancreas CT and MR imaging findings in
seven patients AJR Am J Roentgenol 2003 180 195-9
13 Kim SY Kim JN Kwon SO Cha IH Ryu SH Kim YS Moon JS A case of
duodenal diverticulum mimicking a peripancreatic abscess Korean J
Med 2013 84 249-53
14 Nonaka T Inamori M Kessoku T Ogawa Y Imajyo K Yanagisawa S Shi-
ba T Sakaguchi T Nakajima A Maeda S et al Acute obstructive cholan-
gitis caused by an enterolith in a duodenal diverticulum Endoscopy 2010
42 E204-5
15 Yoneyama F Miyata K Ohta H Takeuchi E Yamada T Kobayashi Y Ex-
cision of a juxtapapillary duodenal diverticulum causing biliary obstruc-
tion report of three cases J Hepatobiliary Pancreat Surg 2004 11 69-72
16 Chiang TH Lee YC Chiu HM Huang SP Lin JT Wang HP Endoscopic
therapeutics for patients with cholangitis caused by the juxtapapillary
duodenal diverticulum Hepatogastroenterology 2006 53 501-5
Kang HS et al bull Lemmelrsquos Syndrome Due to Impacted Enterolith
httpjkmsorg 875httpdxdoiorg103346jkms2014296874
A B C D
Liver
PV
CBD
GB
PAD
Fig 1 Computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) findings of the biliary tract On axial CT scan a high attenuated stone density with internal air (black arrow) is seen on distal common bile duct (CBD) (A) However coronal reconstructed image shows that the stone (black arrow) is not located in the CBD but within the periampullary diverticulum that is filled with air and debris along with mid CBD stricture (white arrow) (B) This finding is depicted in line art to better delineate the anatomical relationship (C) Absence of CBD stone and mid CBD stricture is also demonstrated on MRCP image (D)
A B C
D E F
Fig 2 Endoscopic retrograde cholangiopancreatographic findings of enterolith within the periampullary diverticulum (PAD) and its removal A dark brown pigment stone (white arrow) is seen impacted at the orifice of the PAD (A B) When the stone is pushed upward into the PAD (C) old blood clots is seen gushing out from the PAD orifice (D) The enshyterolith within the PAD is being fragmented and removed with Dormia basket (E F)
following day (Fig 2E F) After the procedure the patient no longer complained of abdominal pain her liver enzyme was normalized and she was discharged without any complication She had been well until 6 months after enterolith removal when the patient visited the outpatient clinic with vague abdo-minal discomfort Laboratory examination only revealed slight-ly increased total bilirubin to 196 mgdL but a large CBD stone
was found on abdominal CT scan (Fig 4A) When the CBD stone was removed by ERCP the stone proved to be brown pigment sludge stone that typically forms in the presence of ascending infection (Fig 4B C) PAD at this time was neither distended nor filled with enterolith Follow-up ERCP was performed again after 6 months but there was no recurrence of CBD stone or en-terolith She remains clinically and radiographically disease
Kang HS et al bull Lemmelrsquos Syndrome Due to Impacted Enterolith
876 httpjkmsorg httpdxdoiorg103346jkms2014296874
A B C
Fig 3 Fluoroscopic images When dye is injected into the PAD an ovoid shaped filling defect (white arrow) can be seen (A) Endoscopic nasobiliary drainage tubogram obtainshyed after decompression of the PAD demonstrates resolved extrinsic compression (B) After completion of enterolith removal filling defect is no longer seen within the PAD (C)
A B C
Fig 4 Removal of common bile duct (CBD) stone Followshyup computed tomography scan taken about 6 months after enterolith removal shows an ovoid stone (white arrow) within the CBD (A) CBD stone (white arrow) removed by Dormia basket (B) proved to be brown pigment sludge stone (C)
free after the last procedure
DISCUSSION
Diverticula of the gastrointestinal tract are outpouchings of all or part of the intestinal wall which can occur anywhere through-out the alimentary tract The most common site of gastrointes-tinal diverticula is colon followed by duodenum which was first described by Chomel in 1710 (3) The detection rate of du-odenal diverticula ranges from 1 to 27 depending on the di-agnostic modalities used and the average age at the time of di-agnosis (1) Among duodenal diverticula PAD is the most com-mon type comprising about 70 to 75 of all duodenal diver-ticula (1) Most PAD are asymptomatic but complications can occur in about 5 of cases and they include bleeding perforation di-verticulitis pancreatitis choledocholithiasis cholangitis jaun-dice enterolith or bezoar formation intestinal obstruction etc Among these complications hepatocholangiopancreatic dis-
ease can seldomly occur in the absence of choledocholithiasis and is termed Lemmelrsquos syndrome (2) Pathologic mechanisms through which Lemmelrsquos syndrome is thought to occur include the following First diverticulitis or direct mechanical irritation of PAD may cause chronic inflammation of ampulla and lead to chronic fibrosis of papilla (papillitis chronica fibrosa) (4) Sec-ond PAD many cause dysfunction in the sphincter of Oddi (5) Third distal CBD or ampulla can be directly compressed me-chanically by PAD that is usually filled with enterolith or bezoar (6 7) In our case enterolith that formed within the PAD did not directly compress the distal CBD but it obstructed the PAD ori-fice instead This obstruction combined with inflammation of the diverticulum and collection of pus-like material within the obstructed PAD seems to have expanded the PAD with resul-tant extrinsic compression of mid CBD (Fig 1) This was quite different from previous cases in which compression occurred at distal CBD PAD normally have a relatively wide orifice There-fore the enterolith bezoar or food material within the PAD is frequently evacuated and thus the symptom could be intermit-
Kang HS et al bull Lemmelrsquos Syndrome Due to Impacted Enterolith
httpjkmsorg 877httpdxdoiorg103346jkms2014296874
tent However PAD in our case had a narrow opening likely due to repeated inflammation of the PAD and this seems to have hindered the clearance of entrapped enterolith out into the du-odenal lumen Enterolith formation within the duodenal diverticula is known to be facilitated in the static environment such as a blind loop after gastrectomy or proximal portion of stricture formed by Crohnrsquos disease or tuberculosis (8) In our case blind loop cre-ated by Billroth II anastomosis seems to have provided a static environment favoring enterolith formation within the PAD Dur-ing enterolith removal CBD was also explored to search for oth-er possible source of obstructive jaundice such as CBD stone since primary biliary stone is known to occur more frequently in the presence of PAD (9 10) One possible mechanism be-hind increased occurrence of primary CBD stone in these pa-tients involves colonization and overgrowth of β-glucuronidase producing bacteria within the PAD that spread into the bile duct which in turn leads to deconjugation of bilirubin glucuronides and eventually results in precipitation of calcium bilirubinate gallstones (11) Although CBD was explored in our case no other etiology of obstructive jaundice could be identified other than extrinsic compression by distended PAD However pri-mary bile duct stone newly developed on follow-up ERCP per-formed 6 months later (Fig 4) The most plausible explanation is that EST performed during CBD exploration at the time of enterolith removal has permitted the occurrence of ascending infection with resultant brown pigment stone formation Diagnosing Lemmelrsquos syndrome could be challenging but being aware of this condition is important to avoid mismanage-ment and it begins with identification of PAD PAD are best de-monstrated using a side-viewing endoscope during ERCP On CT scan and MRCP PAD appear as thin-walled cavitary lesions situated on the medial wall of the duodenum 2nd portion that typically contain gas However PAD are sometimes filled with fluid and can frequently be mistaken for pancreatic pseudocyst pancreatic abscess cystic neoplasm in the pancreas head or even metastatic lymph node (12 13) Therefore high index of suspicion is mandatory to arrive at a correct diagnosis in these patients In our case enterolith within the PAD on axial images was at first mistaken for distal CBD stone due to its distal loca-tion combined with upstream dilatation of the bile duct (Fig 1A) However upon careful scrutinization of the coronal recon-structed images it became evident that the stone was located within the PAD (Fig 1B C) which was eventually confirmed by ERCP (Fig 2) Treatment is generally not recommended in asymptomatic patients or would be conservative management in pauci-symp-tomatic patients Nevertheless since most patients with Lem-melrsquos syndrome present with symptoms related to biliary ob-struction (ie jaundice abdominal pain and cholangitis) as a result of extrinsic compression of CBD some form of treatment
is advocated Therapeutic options in this situation run the gam-ut from endoscopic extraction of entrapped material extracor-poreal shock wave lithotripsy to surgery (diverticulectomy or biliodigestive anastomosis) (7 14 15) The patient in our case was also successfully treated endoscopically by fragmenting and removing enterolith using a Dormia basket It should be kept in mind that not all forms of Lemmelrsquos syndrome are caused by extrinsic compression of CBD by bulging PAD If the under-lying mechanism of Lemmelrsquos syndrome is likely to be due to papillitis chronica fibrosa or sphincter of Oddi dysfunction as mentioned above the simplest and the most appropriate man-agement would be to perform EST (16) In conclusion Lemmelrsquos syndrome is a rare cause of obstruc-tive jaundice that should be included in the differential diagno-sis of biliary obstruction when PAD is present Maintaining a high index of suspicion is imperative to establish an accurate diagnosis since it can mimic other cystic or solid lesions around the pancreas head Symptomatic patient can be successfully managed endoscopically in many instances but recourse to surgical management would be necessary in selected cases
REFERENCES
1 Lobo DN Balfour TW Iftikhar SY Rowlands BJ Periampullary divertic-
ula and pancreaticobiliary disease Br J Surg 1999 86 588-97
2 Lemmel G Die Klinische Bedeutung der Duodenal Divertikel Arch Ver-
dauungskrht 1934 46 59-70
3 Chomel JB Report of a case of duodenal diverticulum containing gall-
stones Histoire Acad R Sci Paris 1710 48-50
4 Manabe T Yu GS Duodenal diverticulum causing intermittent- persis-
tent cholestasis associated with papillitis chronica fibrosa N Y State J
Med 1977 77 2132-6
5 Tomita R Tanjoh K Endoscopic manometry of the sphincter of Oddi in
patients with Lemmelrsquos syndrome Surg Today 1998 28 258-61
6 Rouet J Gaujoux S Ronot M Palazzo M Cauchy F Vilgrain V Belghiti J
OrsquoToole D Sauvanet A Lemmelrsquos syndrome as a rare cause of obstruc-
tive jaundice Clin Res Hepatol Gastroenterol 2012 36 628-31
7 Nishida K Kato M Higashijima M Takagi K Akashi R A case of Lem-
melrsquos syndrome caused by a large diverticular enterolith at the peripapil-
lary portion of the duodenum Nihon Ronen Igakkai Zasshi 1995 32
825-9
8 Shocket E Simon SA Small bowel obstruction due to enterolith (bezoar)
formed in a duodenal diverticulum a case report and review of the liter-
ature Am J Gastroenterol 1982 77 621-4
9 Tham TC Kelly M Association of periampullary duodenal diverticula
with bile duct stones and with technical success of endoscopic retrograde
cholangiopancreatography Endoscopy 2004 36 1050-3
10 Lee JH Lee JS Kim HW Bae SM Kim SH Kang DH Song CS Song GA
Cho M Yang US Association of periampullary diverticula with primary
choledocholithiasis Korean J Gastroenterol 1999 33 252-7
11 Skar V Skar AG Bratlie J Osnes M Beta-glucuronidase activity in the
bile of gallstone patients both with and without duodenal diverticula
Scand J Gastroenterol 1989 24 205-12
Kang HS et al bull Lemmelrsquos Syndrome Due to Impacted Enterolith
878 httpjkmsorg httpdxdoiorg103346jkms2014296874
12 Macari M Lazarus D Israel G Megibow A Duodenal diverticula mim-
icking cystic neoplasms of the pancreas CT and MR imaging findings in
seven patients AJR Am J Roentgenol 2003 180 195-9
13 Kim SY Kim JN Kwon SO Cha IH Ryu SH Kim YS Moon JS A case of
duodenal diverticulum mimicking a peripancreatic abscess Korean J
Med 2013 84 249-53
14 Nonaka T Inamori M Kessoku T Ogawa Y Imajyo K Yanagisawa S Shi-
ba T Sakaguchi T Nakajima A Maeda S et al Acute obstructive cholan-
gitis caused by an enterolith in a duodenal diverticulum Endoscopy 2010
42 E204-5
15 Yoneyama F Miyata K Ohta H Takeuchi E Yamada T Kobayashi Y Ex-
cision of a juxtapapillary duodenal diverticulum causing biliary obstruc-
tion report of three cases J Hepatobiliary Pancreat Surg 2004 11 69-72
16 Chiang TH Lee YC Chiu HM Huang SP Lin JT Wang HP Endoscopic
therapeutics for patients with cholangitis caused by the juxtapapillary
duodenal diverticulum Hepatogastroenterology 2006 53 501-5
Kang HS et al bull Lemmelrsquos Syndrome Due to Impacted Enterolith
876 httpjkmsorg httpdxdoiorg103346jkms2014296874
A B C
Fig 3 Fluoroscopic images When dye is injected into the PAD an ovoid shaped filling defect (white arrow) can be seen (A) Endoscopic nasobiliary drainage tubogram obtainshyed after decompression of the PAD demonstrates resolved extrinsic compression (B) After completion of enterolith removal filling defect is no longer seen within the PAD (C)
A B C
Fig 4 Removal of common bile duct (CBD) stone Followshyup computed tomography scan taken about 6 months after enterolith removal shows an ovoid stone (white arrow) within the CBD (A) CBD stone (white arrow) removed by Dormia basket (B) proved to be brown pigment sludge stone (C)
free after the last procedure
DISCUSSION
Diverticula of the gastrointestinal tract are outpouchings of all or part of the intestinal wall which can occur anywhere through-out the alimentary tract The most common site of gastrointes-tinal diverticula is colon followed by duodenum which was first described by Chomel in 1710 (3) The detection rate of du-odenal diverticula ranges from 1 to 27 depending on the di-agnostic modalities used and the average age at the time of di-agnosis (1) Among duodenal diverticula PAD is the most com-mon type comprising about 70 to 75 of all duodenal diver-ticula (1) Most PAD are asymptomatic but complications can occur in about 5 of cases and they include bleeding perforation di-verticulitis pancreatitis choledocholithiasis cholangitis jaun-dice enterolith or bezoar formation intestinal obstruction etc Among these complications hepatocholangiopancreatic dis-
ease can seldomly occur in the absence of choledocholithiasis and is termed Lemmelrsquos syndrome (2) Pathologic mechanisms through which Lemmelrsquos syndrome is thought to occur include the following First diverticulitis or direct mechanical irritation of PAD may cause chronic inflammation of ampulla and lead to chronic fibrosis of papilla (papillitis chronica fibrosa) (4) Sec-ond PAD many cause dysfunction in the sphincter of Oddi (5) Third distal CBD or ampulla can be directly compressed me-chanically by PAD that is usually filled with enterolith or bezoar (6 7) In our case enterolith that formed within the PAD did not directly compress the distal CBD but it obstructed the PAD ori-fice instead This obstruction combined with inflammation of the diverticulum and collection of pus-like material within the obstructed PAD seems to have expanded the PAD with resul-tant extrinsic compression of mid CBD (Fig 1) This was quite different from previous cases in which compression occurred at distal CBD PAD normally have a relatively wide orifice There-fore the enterolith bezoar or food material within the PAD is frequently evacuated and thus the symptom could be intermit-
Kang HS et al bull Lemmelrsquos Syndrome Due to Impacted Enterolith
httpjkmsorg 877httpdxdoiorg103346jkms2014296874
tent However PAD in our case had a narrow opening likely due to repeated inflammation of the PAD and this seems to have hindered the clearance of entrapped enterolith out into the du-odenal lumen Enterolith formation within the duodenal diverticula is known to be facilitated in the static environment such as a blind loop after gastrectomy or proximal portion of stricture formed by Crohnrsquos disease or tuberculosis (8) In our case blind loop cre-ated by Billroth II anastomosis seems to have provided a static environment favoring enterolith formation within the PAD Dur-ing enterolith removal CBD was also explored to search for oth-er possible source of obstructive jaundice such as CBD stone since primary biliary stone is known to occur more frequently in the presence of PAD (9 10) One possible mechanism be-hind increased occurrence of primary CBD stone in these pa-tients involves colonization and overgrowth of β-glucuronidase producing bacteria within the PAD that spread into the bile duct which in turn leads to deconjugation of bilirubin glucuronides and eventually results in precipitation of calcium bilirubinate gallstones (11) Although CBD was explored in our case no other etiology of obstructive jaundice could be identified other than extrinsic compression by distended PAD However pri-mary bile duct stone newly developed on follow-up ERCP per-formed 6 months later (Fig 4) The most plausible explanation is that EST performed during CBD exploration at the time of enterolith removal has permitted the occurrence of ascending infection with resultant brown pigment stone formation Diagnosing Lemmelrsquos syndrome could be challenging but being aware of this condition is important to avoid mismanage-ment and it begins with identification of PAD PAD are best de-monstrated using a side-viewing endoscope during ERCP On CT scan and MRCP PAD appear as thin-walled cavitary lesions situated on the medial wall of the duodenum 2nd portion that typically contain gas However PAD are sometimes filled with fluid and can frequently be mistaken for pancreatic pseudocyst pancreatic abscess cystic neoplasm in the pancreas head or even metastatic lymph node (12 13) Therefore high index of suspicion is mandatory to arrive at a correct diagnosis in these patients In our case enterolith within the PAD on axial images was at first mistaken for distal CBD stone due to its distal loca-tion combined with upstream dilatation of the bile duct (Fig 1A) However upon careful scrutinization of the coronal recon-structed images it became evident that the stone was located within the PAD (Fig 1B C) which was eventually confirmed by ERCP (Fig 2) Treatment is generally not recommended in asymptomatic patients or would be conservative management in pauci-symp-tomatic patients Nevertheless since most patients with Lem-melrsquos syndrome present with symptoms related to biliary ob-struction (ie jaundice abdominal pain and cholangitis) as a result of extrinsic compression of CBD some form of treatment
is advocated Therapeutic options in this situation run the gam-ut from endoscopic extraction of entrapped material extracor-poreal shock wave lithotripsy to surgery (diverticulectomy or biliodigestive anastomosis) (7 14 15) The patient in our case was also successfully treated endoscopically by fragmenting and removing enterolith using a Dormia basket It should be kept in mind that not all forms of Lemmelrsquos syndrome are caused by extrinsic compression of CBD by bulging PAD If the under-lying mechanism of Lemmelrsquos syndrome is likely to be due to papillitis chronica fibrosa or sphincter of Oddi dysfunction as mentioned above the simplest and the most appropriate man-agement would be to perform EST (16) In conclusion Lemmelrsquos syndrome is a rare cause of obstruc-tive jaundice that should be included in the differential diagno-sis of biliary obstruction when PAD is present Maintaining a high index of suspicion is imperative to establish an accurate diagnosis since it can mimic other cystic or solid lesions around the pancreas head Symptomatic patient can be successfully managed endoscopically in many instances but recourse to surgical management would be necessary in selected cases
REFERENCES
1 Lobo DN Balfour TW Iftikhar SY Rowlands BJ Periampullary divertic-
ula and pancreaticobiliary disease Br J Surg 1999 86 588-97
2 Lemmel G Die Klinische Bedeutung der Duodenal Divertikel Arch Ver-
dauungskrht 1934 46 59-70
3 Chomel JB Report of a case of duodenal diverticulum containing gall-
stones Histoire Acad R Sci Paris 1710 48-50
4 Manabe T Yu GS Duodenal diverticulum causing intermittent- persis-
tent cholestasis associated with papillitis chronica fibrosa N Y State J
Med 1977 77 2132-6
5 Tomita R Tanjoh K Endoscopic manometry of the sphincter of Oddi in
patients with Lemmelrsquos syndrome Surg Today 1998 28 258-61
6 Rouet J Gaujoux S Ronot M Palazzo M Cauchy F Vilgrain V Belghiti J
OrsquoToole D Sauvanet A Lemmelrsquos syndrome as a rare cause of obstruc-
tive jaundice Clin Res Hepatol Gastroenterol 2012 36 628-31
7 Nishida K Kato M Higashijima M Takagi K Akashi R A case of Lem-
melrsquos syndrome caused by a large diverticular enterolith at the peripapil-
lary portion of the duodenum Nihon Ronen Igakkai Zasshi 1995 32
825-9
8 Shocket E Simon SA Small bowel obstruction due to enterolith (bezoar)
formed in a duodenal diverticulum a case report and review of the liter-
ature Am J Gastroenterol 1982 77 621-4
9 Tham TC Kelly M Association of periampullary duodenal diverticula
with bile duct stones and with technical success of endoscopic retrograde
cholangiopancreatography Endoscopy 2004 36 1050-3
10 Lee JH Lee JS Kim HW Bae SM Kim SH Kang DH Song CS Song GA
Cho M Yang US Association of periampullary diverticula with primary
choledocholithiasis Korean J Gastroenterol 1999 33 252-7
11 Skar V Skar AG Bratlie J Osnes M Beta-glucuronidase activity in the
bile of gallstone patients both with and without duodenal diverticula
Scand J Gastroenterol 1989 24 205-12
Kang HS et al bull Lemmelrsquos Syndrome Due to Impacted Enterolith
878 httpjkmsorg httpdxdoiorg103346jkms2014296874
12 Macari M Lazarus D Israel G Megibow A Duodenal diverticula mim-
icking cystic neoplasms of the pancreas CT and MR imaging findings in
seven patients AJR Am J Roentgenol 2003 180 195-9
13 Kim SY Kim JN Kwon SO Cha IH Ryu SH Kim YS Moon JS A case of
duodenal diverticulum mimicking a peripancreatic abscess Korean J
Med 2013 84 249-53
14 Nonaka T Inamori M Kessoku T Ogawa Y Imajyo K Yanagisawa S Shi-
ba T Sakaguchi T Nakajima A Maeda S et al Acute obstructive cholan-
gitis caused by an enterolith in a duodenal diverticulum Endoscopy 2010
42 E204-5
15 Yoneyama F Miyata K Ohta H Takeuchi E Yamada T Kobayashi Y Ex-
cision of a juxtapapillary duodenal diverticulum causing biliary obstruc-
tion report of three cases J Hepatobiliary Pancreat Surg 2004 11 69-72
16 Chiang TH Lee YC Chiu HM Huang SP Lin JT Wang HP Endoscopic
therapeutics for patients with cholangitis caused by the juxtapapillary
duodenal diverticulum Hepatogastroenterology 2006 53 501-5
Kang HS et al bull Lemmelrsquos Syndrome Due to Impacted Enterolith
httpjkmsorg 877httpdxdoiorg103346jkms2014296874
tent However PAD in our case had a narrow opening likely due to repeated inflammation of the PAD and this seems to have hindered the clearance of entrapped enterolith out into the du-odenal lumen Enterolith formation within the duodenal diverticula is known to be facilitated in the static environment such as a blind loop after gastrectomy or proximal portion of stricture formed by Crohnrsquos disease or tuberculosis (8) In our case blind loop cre-ated by Billroth II anastomosis seems to have provided a static environment favoring enterolith formation within the PAD Dur-ing enterolith removal CBD was also explored to search for oth-er possible source of obstructive jaundice such as CBD stone since primary biliary stone is known to occur more frequently in the presence of PAD (9 10) One possible mechanism be-hind increased occurrence of primary CBD stone in these pa-tients involves colonization and overgrowth of β-glucuronidase producing bacteria within the PAD that spread into the bile duct which in turn leads to deconjugation of bilirubin glucuronides and eventually results in precipitation of calcium bilirubinate gallstones (11) Although CBD was explored in our case no other etiology of obstructive jaundice could be identified other than extrinsic compression by distended PAD However pri-mary bile duct stone newly developed on follow-up ERCP per-formed 6 months later (Fig 4) The most plausible explanation is that EST performed during CBD exploration at the time of enterolith removal has permitted the occurrence of ascending infection with resultant brown pigment stone formation Diagnosing Lemmelrsquos syndrome could be challenging but being aware of this condition is important to avoid mismanage-ment and it begins with identification of PAD PAD are best de-monstrated using a side-viewing endoscope during ERCP On CT scan and MRCP PAD appear as thin-walled cavitary lesions situated on the medial wall of the duodenum 2nd portion that typically contain gas However PAD are sometimes filled with fluid and can frequently be mistaken for pancreatic pseudocyst pancreatic abscess cystic neoplasm in the pancreas head or even metastatic lymph node (12 13) Therefore high index of suspicion is mandatory to arrive at a correct diagnosis in these patients In our case enterolith within the PAD on axial images was at first mistaken for distal CBD stone due to its distal loca-tion combined with upstream dilatation of the bile duct (Fig 1A) However upon careful scrutinization of the coronal recon-structed images it became evident that the stone was located within the PAD (Fig 1B C) which was eventually confirmed by ERCP (Fig 2) Treatment is generally not recommended in asymptomatic patients or would be conservative management in pauci-symp-tomatic patients Nevertheless since most patients with Lem-melrsquos syndrome present with symptoms related to biliary ob-struction (ie jaundice abdominal pain and cholangitis) as a result of extrinsic compression of CBD some form of treatment
is advocated Therapeutic options in this situation run the gam-ut from endoscopic extraction of entrapped material extracor-poreal shock wave lithotripsy to surgery (diverticulectomy or biliodigestive anastomosis) (7 14 15) The patient in our case was also successfully treated endoscopically by fragmenting and removing enterolith using a Dormia basket It should be kept in mind that not all forms of Lemmelrsquos syndrome are caused by extrinsic compression of CBD by bulging PAD If the under-lying mechanism of Lemmelrsquos syndrome is likely to be due to papillitis chronica fibrosa or sphincter of Oddi dysfunction as mentioned above the simplest and the most appropriate man-agement would be to perform EST (16) In conclusion Lemmelrsquos syndrome is a rare cause of obstruc-tive jaundice that should be included in the differential diagno-sis of biliary obstruction when PAD is present Maintaining a high index of suspicion is imperative to establish an accurate diagnosis since it can mimic other cystic or solid lesions around the pancreas head Symptomatic patient can be successfully managed endoscopically in many instances but recourse to surgical management would be necessary in selected cases
REFERENCES
1 Lobo DN Balfour TW Iftikhar SY Rowlands BJ Periampullary divertic-
ula and pancreaticobiliary disease Br J Surg 1999 86 588-97
2 Lemmel G Die Klinische Bedeutung der Duodenal Divertikel Arch Ver-
dauungskrht 1934 46 59-70
3 Chomel JB Report of a case of duodenal diverticulum containing gall-
stones Histoire Acad R Sci Paris 1710 48-50
4 Manabe T Yu GS Duodenal diverticulum causing intermittent- persis-
tent cholestasis associated with papillitis chronica fibrosa N Y State J
Med 1977 77 2132-6
5 Tomita R Tanjoh K Endoscopic manometry of the sphincter of Oddi in
patients with Lemmelrsquos syndrome Surg Today 1998 28 258-61
6 Rouet J Gaujoux S Ronot M Palazzo M Cauchy F Vilgrain V Belghiti J
OrsquoToole D Sauvanet A Lemmelrsquos syndrome as a rare cause of obstruc-
tive jaundice Clin Res Hepatol Gastroenterol 2012 36 628-31
7 Nishida K Kato M Higashijima M Takagi K Akashi R A case of Lem-
melrsquos syndrome caused by a large diverticular enterolith at the peripapil-
lary portion of the duodenum Nihon Ronen Igakkai Zasshi 1995 32
825-9
8 Shocket E Simon SA Small bowel obstruction due to enterolith (bezoar)
formed in a duodenal diverticulum a case report and review of the liter-
ature Am J Gastroenterol 1982 77 621-4
9 Tham TC Kelly M Association of periampullary duodenal diverticula
with bile duct stones and with technical success of endoscopic retrograde
cholangiopancreatography Endoscopy 2004 36 1050-3
10 Lee JH Lee JS Kim HW Bae SM Kim SH Kang DH Song CS Song GA
Cho M Yang US Association of periampullary diverticula with primary
choledocholithiasis Korean J Gastroenterol 1999 33 252-7
11 Skar V Skar AG Bratlie J Osnes M Beta-glucuronidase activity in the
bile of gallstone patients both with and without duodenal diverticula
Scand J Gastroenterol 1989 24 205-12
Kang HS et al bull Lemmelrsquos Syndrome Due to Impacted Enterolith
878 httpjkmsorg httpdxdoiorg103346jkms2014296874
12 Macari M Lazarus D Israel G Megibow A Duodenal diverticula mim-
icking cystic neoplasms of the pancreas CT and MR imaging findings in
seven patients AJR Am J Roentgenol 2003 180 195-9
13 Kim SY Kim JN Kwon SO Cha IH Ryu SH Kim YS Moon JS A case of
duodenal diverticulum mimicking a peripancreatic abscess Korean J
Med 2013 84 249-53
14 Nonaka T Inamori M Kessoku T Ogawa Y Imajyo K Yanagisawa S Shi-
ba T Sakaguchi T Nakajima A Maeda S et al Acute obstructive cholan-
gitis caused by an enterolith in a duodenal diverticulum Endoscopy 2010
42 E204-5
15 Yoneyama F Miyata K Ohta H Takeuchi E Yamada T Kobayashi Y Ex-
cision of a juxtapapillary duodenal diverticulum causing biliary obstruc-
tion report of three cases J Hepatobiliary Pancreat Surg 2004 11 69-72
16 Chiang TH Lee YC Chiu HM Huang SP Lin JT Wang HP Endoscopic
therapeutics for patients with cholangitis caused by the juxtapapillary
duodenal diverticulum Hepatogastroenterology 2006 53 501-5
Kang HS et al bull Lemmelrsquos Syndrome Due to Impacted Enterolith
878 httpjkmsorg httpdxdoiorg103346jkms2014296874
12 Macari M Lazarus D Israel G Megibow A Duodenal diverticula mim-
icking cystic neoplasms of the pancreas CT and MR imaging findings in
seven patients AJR Am J Roentgenol 2003 180 195-9
13 Kim SY Kim JN Kwon SO Cha IH Ryu SH Kim YS Moon JS A case of
duodenal diverticulum mimicking a peripancreatic abscess Korean J
Med 2013 84 249-53
14 Nonaka T Inamori M Kessoku T Ogawa Y Imajyo K Yanagisawa S Shi-
ba T Sakaguchi T Nakajima A Maeda S et al Acute obstructive cholan-
gitis caused by an enterolith in a duodenal diverticulum Endoscopy 2010
42 E204-5
15 Yoneyama F Miyata K Ohta H Takeuchi E Yamada T Kobayashi Y Ex-
cision of a juxtapapillary duodenal diverticulum causing biliary obstruc-
tion report of three cases J Hepatobiliary Pancreat Surg 2004 11 69-72
16 Chiang TH Lee YC Chiu HM Huang SP Lin JT Wang HP Endoscopic
therapeutics for patients with cholangitis caused by the juxtapapillary
duodenal diverticulum Hepatogastroenterology 2006 53 501-5
